THE CHANGING NATURE OF PREOPERATIVE EVALUATION

Preoperative evaluation strives to answer three questions: Is the patient in optimal health? Can, or should, the patient's physical or mental condition be improved before surgery? Does the patient have any health problems or use any medications that could unexpectedly influence perioperative events? Such an evaluation must include the long-accepted standard practices: review of hospital chart(s) and prior anesthesia records, consultation with the primary care physician, history-taking, physical examination, evaluation of laboratory tests obtained, ordering of additional laboratory tests, and discussion of perioperative anesthesia plans (including alternatives for intraoperative and postoperative analgesia) with the patient in a way that provides accurate information and reduces patient anxiety. However, the practice of medicine has changed. The cost-conscious and outcome-focused environment of the 2000s has made it difficult for anesthesiologists to achieve these goals using the style of the 1980s and earlier.

For example, the increased need to minimize costs means fewer or no preoperative hospital days for the patient. More than 65% of all operations are performed on an outpatient basis, almost 10% in the surgeon's office, and another 20% to 30% as morning admissions. Unfortunately, the increasing age of patients often means a greater likelihood of concurrent disease. Unlike the old days, when the entire evening before surgery could be spent learning about the medically complex patient, anesthesiologists are now being asked to perform preoperative evaluation as they "run" from case to case. They are being asked to deliver more for less and at the same time to meet the continuing demand of administrators and surgeons to shorten turnover times. In such time-pressured situations, the anesthesiologist may be justifiably uncomfortable about the adequacy and comprehensiveness of his or her preoperative evaluation. Did I remember to ask the patient whether he or she had a drink during the past 72 hours, or whether he or she has ever had a problem with drinking? (These are currently the two most sensitive and specific questions to ask when trying to determine the likelihood of alcoholism.^{[75] [76]} ) Did I forget to ask other questions—for example, whether any family members had hepatitis?

It is very difficult to make an adequate preoperative evaluation in 5 to 15 minutes, and it is impossible to change any therapy or optimize any care that requires more than 10 minutes without increasing costs and inconveniencing all concerned. Furthermore, the pressure to proceed, even when there may be increased or unknown risk, is much greater when time is short than when such evaluations are done in advance. Frequently, old records are not available.^{[77] [78]} Also, the pressure to proceed quickly probably makes the consent process less informed and the discussion of anxiety relief and preoperative pain therapy plans less thorough. Also, the patient and significant others have little or no time to "digest" information about what to expect regarding the perioperative care plan.

Do we need to change our system? Clearly, a change is needed if preoperative assessment is to be adequate, and more so if anesthesiology as a specialty is to continue to lead the movement fostering patient safety, optimizing perioperative outcome, and motivating a higher quality of life with fewer health care costs. To perform these assessments efficiently, the anesthesiologist needs to know about the patient, to educate the patient, and to motivate the patient.

Preoperative evaluation is intrinsically valuable, and interacting with the patient in this way is an enjoyable and productive part of the practice of anesthesia and can continue to make anesthesia a specialty integral to and valuable for the health of the nation and of the individual patient. Also, for the practical-minded, inadequate preoperative assessment is now one of the top three causes of lawsuits against anesthesiologists. Nevertheless, in the current atmosphere, there is not enough time to assess the patient preoperatively using traditional methods. Before suggesting solutions to this problem, this chapter will evaluate the importance of preoperative assessment, as well as the conditions that may be sought and determined from such assessment.